Supervised Access Program Step 1 of 5 20% SUPERVISED VISIT / EXCHANGE APPLICATION FORM For further information or help completing this form, contact the Program Coordinator at sap@algomafamilyservices.org or at (705) 945-5058 ext. 2707 or 1-800-461-2237 x 2707.Date Requested * Required MM slash DD slash YYYY Service Requested * RequiredSelect A ServiceVisitsExchangesVirtual Visits Name * Required First Last Date of Birth * RequiredMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Section BreakRelation * RequiredMotherFatherOtherOther ( Please Specify ) * RequiredPlease Select * RequiredPrimary ResidenceVisiting PartyJoint Custody Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneMobileWork PhoneEmail Other parent / guardianName First Last RelationMotherFatherOther (Please Specify)Other ( Please Specify ) * RequiredSelect Any That ApplyPrimary ResidenceVisiting PartyJoint custodyChildren's InformationPlease Click ( + ) To Add A ChildFirst NameLast NameDate of Birth (DOB) Emergency contact informationName First Last PhoneMobileRelationship Applicant's lawyer informationName First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneEmail Office of the Children's Lawyer (if involved)Name First Last Phone CHILDREN'S AID INVOLVEMENTIs the Children's Aid Society presently involved with your family Yes No Select Investigation / Protection concerns Voluntarily Other Worker Name First Last PhoneLegal InformationReferral Source Court ordered Child Welfare Lawyer O.C.L. Self-referral Other Reason For Referral Concern regarding parenting ability Concern regarding abduction History of alcohol or drug abuse History of psychiatric illness Partner Abuse Other Concern Regarding Child Abuse Interference With Access By Either Party Long Absence Of Either Party Unresolved Conflict Between Parties Section BreakDo you agree with this application Yes No Is there a court order for supervised access Yes No Are there on-going court proceedings Yes No Is there a restraining order in place Yes No Is there a criminal conviction Yes No Criminal conviction reasonPREVIOUS VISITS ARRANGEMENTS Supervised access Unsupervised access No previous access Last AccessMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Important information when submitting an application 1) Each parent/guardian must complete and submit separate application form. 2) You will receive a confirmation that we have received your application. Once both applications are received an intake appointment will be booked. 3) At intake you will need to provide a copy of your court order, minutes of settlement, endorsement or mediation agreement in addition to any child welfare documents, past/present restraining orders, bail conditions and proof of income if any. 4) Application sent over the internet cannot be guaranteed to be 100% secure, if you have privacy concerns please contact the coordinator at ( 705) 945-5058 ext. 2707CAPTCHA
